***We are only able to address a maximum of one issue per visit. We will schedule you for a follow-up appointment for additional evaluation if necessary.***

*We will need a referral from your primary care physician prior to your appointment.

I certify that the information given by me in applying for insurance and/or MassHealth payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or MassHealth benefits, and I authorize payment of these benefits to Kirsch Dermatology on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of agency shown and authorizes my doctor to act as my agent, as above.

PRIOR AUTHORIZATIONS:
Kirsch Dermatology will complete prior authorizations for medications if the out-of-pocket cost exceeds $100. We cannot complete prior authorizations if the cost is less than $100 due to the excessive administrative burden this places on our practice. Thank you for your understanding.

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

• I have the right to review this facility’s Notice of Information practices prior to signing this consent;
• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

HIPAA Contact Consent:

*Do you authorize medical information regarding your care such as test results, appointments, billing information, etc. to be shared with someone other than yourself? (If the authorized person/organization is not a healthcare provider, they may further disclose the protected health information and it may no longer be protected by the federal health information privacy laws.) EXAMPLE: Spouse or Family member.

You may revoke this consent at any time in writing once signed. The person/persons named MUST give Kirsch Dermatology your full name and date of birth in order to receive any information. 

I voluntarily consent to the rendering of care, including treatment. I understand that I am under the care and supervision of Kirsch Dermatology.

I further consent to the examination for diagnostic, investigational purposes, and disposal by authorities of the above-named medical facility or it designates herein, of any tissue or parts which may be removed.

I consent for medical photographs to be used by the staff or representatives of Kirsch Dermatology. I understand that the images will be placed in my medical record and may be used for evaluation by employees of Kirsch Dermatology. By consenting to the use of these medical photographs, I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also give permission for transfer of these photographs via a non-encrypted email exclusively for the purposes of third-party diagnostics, treatment, and continuing medical care (e.g. communication with my primary care physician).

If I wish to withdraw my consent in the future, I may do so with a written request.

Kirsch Dermatology has/will explain to the me/my family/my guardian the nature of my condition, the nature of the procedure, and the benefits to be reasonably expected compared to alternative approaches. Kirsch dermatology has/will discuss the likelihood of major risks or complications of this procedure including specific risks and (if applicable) drug reactions, hemorrhage, infection, and or complications. Kirsch Dermatology has also indicated that with any procedure that there is also the possibility of an unexpected complication.

MEDICATION HISTORY: Patient medication history is a list of prescription medicines that our practice providers, or other providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The medication history may include sensitive information including, but not limited to, medications related to mental health conditions, sexually transmitted diseases, substance (drug and alcohol) abuse and HIV/AIDS.
Obtaining your medication history is very important in helping healthcare providers treat you properly and in avoiding potentially dangerous drug interactions. Please note that some pharmacies do not make drug history available. Your drug history may not include drugs purchased without using your health insurance as well as over-the-counter drugs, supplements, or herbal remedies that patients take on their own.
By signing this consent form, you are giving your healthcare provider permission to collect information about your medication history, and it gives permission to your pharmacy and your health insurer to disclose your medication history. This includes specific consent to release sensitive health information listed in the first paragraph.

*A Kirsch Dermatology team member will contact you within 1-2 business days by text message. Thank you for your patience!